What your representatives in Washington say about health care

Here are responses to your questions about health care, edited for length and relevance, by Sen. Sherrod Brown and Rep. Joyce Beatty, both Democrats, and Sen. Rob Portman and Reps. Pat Tiberi and Steve Stivers, all Republicans.

Since the Democrats oppose the GOP's proposed Obamacare replacement, they were asked how they would improve the 2010 health care law.

Republicans were asked somewhat different questions on the GOP proposal.

Q: While you oppose the new Republican plan to repeal and replace Obamacare, what changes do you think are needed to the Affordable Care Act? How would you address the rising cost of health insurance premiums and lack of health insurers in many areas of Ohio?

Brown

A: Health care costs have always been going up, and the ACA has kept them from going up as dramatically as they were. One of the ways to fix that in part is to get more young people in these insurance plans — not a repeal to take away people’s benefits.

The other most important thing is to work to restrain drug costs and unfortunately the drug industry has far too much influence with House Republicans and they won’t even touch that one. But that’s where a lot of the rising costs have come from.

Beatty

A: I look at the Affordable Care Act like Medicare. We knew when it first came out that it was not going to be perfect. But yet we rolled it out and who would have ever thought we’d have almost 30 million people on it.

I think we need to make some adjustments with the insurers you know, because some of the complaints are valid that we probably did not develop enough of a cohesive relationship with the providers.

I think we have to have a better plan of encouraging people to be enrolled. It was probably rolled out too fast without thinking through what happens if enough people don’t get enrolled on the front end to take care of those who are really sick.

Because the good thing we had we gave the stipends to those who really couldn’t afford it and now they’re taking that away. So one of the things that was one of our best things was you take a young person and when it first started out, remember they were going to fine them $90 if they didn’t have insurance but to get insurance was only $85. Half my office that was in in their 20s and 30s all signed up and they were paying little or nothing.

Now we need more of the people on the back end in my age group to sign up on it. I’m in the Affordable Care Act. It was mandatory. I got in it and I look at myself as someone who helps balance the costs for those who couldn’t afford it.

Q: House Republicans want to end Medicaid expansion in 2020 and substitute a cap on future Medicaid dollars to the states based on program growth and medical inflation, which could cost Ohio billions of dollars. Do you support this plan?

Portman

A: Look, the status quo under the Affordable Care Act is not acceptable, but I still do have concerns about the House bill with regard to Medicaid.

They improved the bill and we’ll see whether that holds or not because some members over there want to offer amendments to pull it back.

Meaning if you are on Medicaid in Ohio now and there are 700,000 people, you have the ability between now and 2020 to stay on that program. That’s the change that the House made. Originally they were not going to permit people to stay on if they fell off and that would have resulted in the majority of people getting this care losing this care. So that was not a good result for Ohio because we have a lot of people who need this coverage. And we have a high percentage of those people who need substance abuse and mental health treatment, in particular heroin and prescription drug treatment programs are part of that.

We think between mental health and substance abuse, it’s about 50 percent of that funding. You’ve just got a real problem in our state right now with this epidemic of opioid addiction.

I think it is better to allow people during this transition to have this coverage because the state doesn’t have the time to put together the alterative before 2020. Once they have the alternative in place in 2020 then it’s going to be based on population growth and medical inflation. It will be at a different federal percent responsibility ... which is 62 percent under Ohio for general Medicaid.

The Medicaid expansion will continue at the higher match rate, but they won’t take new people. So it’s complicated. But bottom line is you want to make sure Ohio has the ability to take care of these people and I do think having it per capita is better because you get population growth and you get medical inflation in terms of increasing the amount is provided every year.

What I have been looking for though is more flexibility for Ohio to be able to manage the program. The most important thing to me is that once we get through the transition that Ohio and other states have real flexibility so they can better manage the Medicaid program to meet people’s needs.

This is what the Republicans governors have been asking for. They are OK with the gradual transition for the most part, but they want to make sure they have the ability to really take the rules and regulations that make it a one-size-fits-all program and make it a program that works for their state. And for Ohio, we know how to do this. We actually have kept our Medicaid costs under the national average over the last few years.

We’ve got about 80 percent of the people in Medicaid in a managed care program, which means private-pay insurance. So you don’t show up emergency room with a Medicaid card. You’ve got an Anthem card. So that’s flexibility Ohio is looking for and Ohio tried to get that flexibility with a waiver and was turned down in the last administration. This administration has given signals that it will provide that flexibility.

I still have concerns because I want to be sure these people are not going to lose coverage. That would be bad. They’d end up in the emergency room, which costs everybody more. But I think that there is a way to take this House product and make it better and that’s what I am going to be working to do.

Tiberi

A: Let me put some context into this because I supported the governor’s Medicaid expansion. I understood why governors would do that when we passed Obamacare. But two things are really important. No. 1 at the federal level, Medicaid is on an unsustainable fiscal path. We all know that. It’s a driver of our structural debt.

And quite frankly, the fact of the matter is — and most Americans aren’t even aware of this — it is a policy that I believe creates a gross inequity because traditional Medicaid, which has been around since 1965, is a program for the poor, for the disabled and for children all below poverty. And they continue to get 62 percent reimbursement from the federal government for their care. Sixty two percent to Ohioans who are 100 percent of (the federal poverty rate) and lower.

And while Medicaid expansion has been important to deal with issues in Ohio, it is at 95 percent federal reimbursement right now and goes to 90 percent in perpetuity. Now how can you explain to me or to anybody else that the truly poor children below 100 percent of poverty, the disabled, the poor elderly, the poorest of our society, should get reimbursed less from the federal government than able-body adults at over 100 percent of the federal poverty rate)? It is unsustainable. It’s not fair.

We don’t end the ability of governors to have Medicaid expansion. They can continue to have Medicaid expansion, just at that rate that the very poor get. In Ohio, that’s 62 percent. And governors are mad that they are not getting free money from Washington, D.C., and I get that. I’d want free money too. But we have to look at the context of this program. And in the end, we give governors more flexibility than they’ve ever had before. And we grandfather every single individual that they have signed up for this program and allow them to be reimbursed at the 90 percent level as long as they are on Medicaid expansion, which I believe is very fair.

But again governors want to run this program and have unprecedented levels of reimbursement they’ve never had in the program. Medicaid numbers at the federal level have tripled since I became a congressman and according to CBO will double in the next eight years on the current path if it’s not changed.

So we’re all for continuing this federal-state program where the federal government provides a majority of the funding, but the states have a share that they have traditionally had since 1965, included in the Medicaid expanded population.

Q: Compared to the 2010 health law, the new plan offers refundable tax credits ranging from $2,000 to $4,000 according to age. But critics suggest that might work against people in their late 50s and early 60s who have more expensive health costs. Do you agree with the tax credits the way they are or should they be adjusted?

Portman

A: The status quo under the Affordable Care Act is not working for Ohio and I think most people now acknowledge that because premiums and deductibles have skyrocketed in Ohio. Ninety-one percent increase in the individual market and the 82 percent increase in the small business market are not sustainable. So we do need to do something.

The tax credit should be adjusted to be sure they are targeted to those who need the help the most. In Ohio, if you are older it is more expensive to get health care insurance so I think it should be targeted more toward those who are older, that would be people in their 50's and 60's, but second it should be targeted to those who need the help most in terms of their income level.

There should means-testing in the tax credits up to the $75,000 level of income. It is means-tested beyond $75,000. That would enable more people to be able to afford premiums.

Anybody who looks at our health-care system says gosh, (it would be better) if you could have more competition between insurance companies, more competitions between providers, more choices for consumers and fewer rules and regulations that ties the hands of small business trying to provide health care.

There are ideas in the House bill that do try to bring these costs down. So comparing the cost now versus the cost after these reforms are put in place is not necessarily the fair comparison.

There’s also in the House bill there’s also this thing called the Patient State Stability Fund. The idea there is that you have funds available to Ohio and other states to be able to have a high risk pool. We think in Ohio, it could be $95 million a year and that’s for the first two years, then the state starts to pay 7 percent.

But that would help us in Ohio because one of the reasons that premiums go up is because the pool has people with higher health care costs because they have chronic diseases or other problems like substance abuse and just need to go to the doctor regularly.

“If you can have a high risk pool where you are helping some of those people deal with their very serious chronic health care problems, that should help.

Tiberi

A: I’m open to that. But as we know from the data from The Center for Medicaid and Medicare, older people tend to have more health care costs. Now there are exceptions to that, but generally speaking the older you get the more expensive your health care is.

And so what we do in our bill is we treat individuals who don’t have employer-provided health care, Medicare, Medicaid, Veterans care, Tri-Care, which is less than 10 percent of Americans who are on the exchange, so the individual market, if you will, we say to them we treat you the same way that we treat employer-provided health care. Everybody who has employer provided health care gets a tax benefit through their employer. So they are getting a tax-free benefit. But if you are a small business person and you get your health care on the individual market, you are not getting any tax benefit. So we designed this credit to make refundable (for those) who don’t have enough money to file taxes. By the way, they might even be working, but they don’t have enough money to file taxes.

So we give them a tax credit and we do it based upon age. So critics are using the current law on health-care costs rather than what we believe will be the future law. We believe with the way we are designing this, there will be more competition on the exchange. As you know the exchanges have attracted fewer plans ... that will continue next year by the way. It will finally change after 2020 when our law goes into effect because we don’t pull the rug out from under anybody under the current law. But we will have more competition, we’ll have young people beginning to buy health insurance again, which the Congressional Budget Office has concurred with. We don’t mandate it through the tax code, but we believe that when you get young people involved in the market that’ll bring down costs and these tax credits will be more meaningful than they would be under today’s marketplace.

Q: Ohio Gov. John Kasich, as well as the national organizations for doctors, hospitals, retired people, and others, already have come out against the House Republican leadership’s plan to replace Obamacare. How do you respond to these three criticisms:

1. Ending the Medicaid expansion and changing the health-care exchanges will result in fewer people with health-care coverage, especially those dealing with mental illness or drug addictions.

Stivers

A: “Well, obviously, there are a lot of people who have an ox who might get gored when you reform health care

Hospitals, as one of the callers said on my telephone town hall tonight, they acknowledged that a lot of hospitals are making a lot of money under the current system of Obamacare. That’s why the American Hospital Association endorsed and supported the Obamacare bill.

Any change to that might be something they’d oppose. Obamacare puts hospitals right at the center of everything and has allowed hospitals to buy up primary-care practices. It pays hospitals more when they buy doctor’s practices for the same thing the doctors were doing the day before, it pays them almost 30 percent more and then it creates a huge competitive problem of allowing a hospital to own its own referral source of the primary-care network. So of course hospitals are opposed to it.

Some doctors had some concerns about the coverage numbers. This is not a one-step replacement plan. It’s a multi-step replacement plan and the second and third steps include working to make health care more affordable, working to create more American jobs that have good health care that will replace the insurance that some people have under the Affordable Care Act. And if we can replace somebody that’s on Medicaid expansion with employer-sponsored health care and a job that pays them more, I consider that a victory, not a loss.

It’s a multi-step process, if we can expand jobs, grow our economy, create jobs that have health care, that’s a better outcome for people than being on a poverty-based program. I want to increase their wages and give them health care. That’s a win.

2. Phasing out Medicaid expansion’s enhanced matching funds will cost a state like Ohio an estimated $1.5 billion each year if coverage is to continue.

A: I don’t think that is a correct number. (Note: It was calculated by the Kasich administration.) We create a per-capita system where we pay states with Medicaid expansion more than states that didn’t do Medicaid expansion. So they get extra money for the Medicaid expansion population. And they’ll have to manage it to make sure they use that money wisely but they get additional money for the Medicaid expansion population. They don’t take on the entire responsibility of it.

3. Compared to the Affordable Care Act, the new plan generally favors higher-income and younger people, at the expense of older and poorer people.

A: I don’t believe that to be true. The refundable tax credit goes up as your age goes up and it also encourages people to choose a plan that they like and, I think that the precondition that a lot of people that make these arguments claim is that poor people can’t manage own affairs, can’t buy their own insurance, can’t buy a plan that works for them.

Just because somebody’s poor doesn’t mean they can’t manage their own affairs. They can, they understand what works for them and they’ll buy a plan that works for them under this system.